When turning a male client who has been lying on his back for 2 hours, the nurse notes that the skin over his sacrum is very white. The client is repositioned and when the nurse reassesses the sacrum 2 hours later, the area is bright red. Which intervention should the nurse implement?

Apply a warm compress to the sacral area.

Wash the area with soap and water.

Reassess and turn the client in 30 minutes.

Massage the reddened area with lotion.

Answer and Explanation

The Correct Answer is C

A. Applying a warm compress does not address the prevention of pressure ulcers and could potentially exacerbate skin issues. The primary focus should be on preventing further pressure.
B. Washing the area with soap and water does not effectively address the issue of pressure ulcer risk or the need for repositioning to alleviate pressure.
C. Reassessing and turning the client every 30 minutes helps prevent the development of pressure ulcers by relieving pressure on vulnerable areas, which is crucial for maintaining skin integrity.
D. Massaging the reddened area can cause further damage and is not recommended. Proper repositioning and pressure relief are the appropriate interventions.

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Correct Answer is D

Explanation

A. Muscle strength and tone are important assessments but are not directly related to the safe use of a heating pad.
B. The rebound phenomenon, where the effects of heat application reverse after prolonged exposure, is a consideration, but not as crucial as assessing for neurosensory impairment.
C. Limitations to range of motion may be important for mobility assessments but are less relevant to the safe application of heat therapy.
D. Assessing the degree of neurosensory impairment is most important before applying a heating pad. If the client has impaired sensation, they may not be able to detect if the heating pad is too hot, which could lead to burns or other injuries.

A. Instruct the client to use guided imagery and slow rhythmic breathing. B. Place a hot water circulation device, such as an Aqua K pad, to the operative site. C. Tune to a television show or easy listening music to provide distraction. D. Provide at least 20 minutes of back massage and gentle effleurage.

Correct Answer is A

Explanation

A. Guided imagery and slow rhythmic breathing are effective techniques for managing moderate pain and can help reduce the perception of pain by promoting relaxation. These methods can be used in conjunction with pain medication to enhance overall pain management.
B. Applying a hot water circulation device may not be appropriate for postoperative pain, as heat could interfere with healing or cause complications. The focus should be on pain management strategies that are safe for the surgical site.
C. While distraction methods like television or music can help, they are generally less effective for managing moderate pain compared to relaxation techniques and additional pain management strategies.
D. Providing a back massage may not be appropriate immediately after thoracic surgery, as it could cause discomfort or interfere with the surgical site. Effective pain management should prioritize safe and recommended interventions.

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When turning a male client who has been lying on his back for 2 hours, the nurse notes that the skin over his sacrum is very white. The client is repositioned and when the nurse reassesses the sacrum 2 hours later, the area is bright red. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

Correct Answer is D

Explanation

A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a pain scale of 1 to 10. After placing a call to the healthcare provider, which action should the nurse implement?

Correct Answer is A

Explanation

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When turning a male client who has been lying on his back for 2 hours, the nurse notes that the skin over his sacrum is very white. The client is repositioned and when the nurse reassesses the sacrum 2 hours later, the area is bright red. Which intervention should the nurse implement?